Childhood critical illness and injury leads to significant morbidity and mortality. Care for the most severely ill children within non-tertiary (Level II) pediatric intensive care units (PICUs) is associated with higher odds of mortality in comparison with care of similar children within tertiary (Level I) PICUs. Unfortunately, no guidelines exist to aid the transfer of children from Level II PICUs to the highly specialized Level I PICUs. The proposed project aims to determine the salient clinical factors that influence fatality status at the Level I PICU, explore the clinical and decision-making characteristics associated with transfer of children from Level II to Level I PICUs. The project is organized in two phases, and focuses on the clinically important diagnoses of sepsis and respiratory failure: (1) Comparative assessment of patient clinical characteristics at Level II PICUs according to transfer status to Level I PICUs;(2) Identification of decision-making factors that encourage or discourage transfer from Level I to II PICUs. Phase A will be based on analysis of data abstracted from medical chart records from seven collaborating Level II PICUs. Phase B will include interviews of decision makers using qualitative methods and quantitative rankings of case-based scenarios. Career development activities during these phases of research will include formal training in statistical analysis of clinical data, qualitative methods, and clinical decision-making, with guidance and direction from a panel of dedicated and experienced mentors. By the end of the proposed research project, the candidate will be an expert in healthcare delivery to critically ill and injured children and will submit an independent investigator-initiated grant application for further advancement of his goal to improve the care of critically ill children. The project aims to understand, as an initial step toward improving, the clinical decision making and environmental factors that influence the level of care provided to critically ill and injured children. Because specialized resources for critical care are scarce and expensive, a greater understanding of the current basis for resource allocation is an essential step toward developing an enhanced system that is equitable, efficient, and effective.